Journal of VitreoRetinal Diseases

This article investigates the relationship between visual acuity (VA), total area of geographic atrophy (GA), and percentage of foveal GA.

A multicenter, retrospective, cross-sectional study was conducted of patients with GA due to age-related macular degeneration. Demographics, VA, fundus autofluorescence (FAF), and spectral-domain optical coherence tomography (SD-OCT) images were collected. Using FAF images aided by SD-OCT, fovea-sparing status, GA pattern, total GA size, and percentage of GA covering the foveal area—within a 1.5-mm-diameter circle centered on the fovea centralis—were assessed. Univariable and multiple linear regression analyses were performed.

Fifty-four eyes (mean age, 78.7 ±7.7 years [SD], 60.0% female) were studied. Mean VA was 0.8 ± 0.6 logarithm of the minimum angle of resolution (Snellen equivalent 20/126 ± 20/80), mean total GA 8.8 ± 6.7 mm², and mean percentage of foveal GA was 71.5 ± 30.9%. Of all assessed eyes, 48.2% (n = 26) presented with multifocal GA, and 18.5% (n = 10) had foveal sparing. Multiple regression analysis revealed that, controlling for age and GA pattern, the percentage of foveal GA presented a statistically significant association with VA (ß = 0.41, P = .004). No significant associations were observed with mean total GA size, while controlling for the same variables (ß = 0.010, P = .440).

Percentage of foveal GA was significantly associated with VA impairment, although the same was not verified for total GA area. These findings suggest that percentage of foveal GA may represent a more useful tool for assessing the impact of GA on VA. Further validation is needed in larger cohorts.

This article identifies subclinical microvascular changes in systemic lupus erythematosus (SLE) patients using vascular perfusion densities derived from optical coherence tomography angiography (OCTA).

A retrospective review was performed on individuals with SLE (10 eyes of 5 patients) and age-matched controls imaged with a spectral-domain OCT system (XR Avanti, Optovue, Inc). A split-spectrum amplitude-decorrelation algorithm (SSADA) generated OCTA of the superficial retinal capillaries, deep retinal capillaries, and foveal avascular zone (FAZ). Skeletonized OCTAs were used to create capillary vessel density (VD) values for each image. VD values were compared with clinical staging, and groups were compared using Kruskal–Wallis and Mann–Whitney tests.

Both the superficial (SCP) and deep capillary plexus (DCP) had a statistically significant decrease in VD in the SLE group when compared with the control group (P < .05). The average VD ± SD for normal individuals in the 3 mm × 3 mm scans was 26.11 ± 1.2 and 37.45 ± 1.8 for the SCP and DCP, respectively. For SLE patients the mean ± SD was 18.46 ± 0.84 and 30.22 ± 1.5 for SCP and DCP, respectively. The mean FAZ was found to be 0.207 mm ± 0.02 for healthy controls and 0.350 mm ± 0.02 for SLE patients (P < .001).

In this paper we demonstrate a significantly enlarged FAZ and decreased VD in a small sample of patients with lupus. The SCP VD demonstrated a dose-response–type negative relationship with increased systemic lupus severity. Larger-sample, prospective studies may allow us to further characterize subclinical SLE pathology with OCTA, and OCTA may further provide a means for monitoring the severity or progression of other microvascular diseases.

This study assesses the frequency of projection artifacts in optical coherence tomography angiography (OCTA) en face images and compares images before and after applying a 3-dimensional projection artifact removal (3D-PAR) algorithm.

This is a single-center, retrospective study that included consecutive patients with any underlying diagnosis who had OCTA obtained from January to March 2017. Patients with various retinal diseases and also healthy eyes were included. All participants underwent imaging with a scan area of 3 mm × 3 mm. The 4 default en face slabs were analyzed: superficial capillary plexus (SCP), deep capillary plexus (DCP), outer retina (OR), and choriocapillaris (CC). Images were qualitatively analyzed before and after 3D-PAR by 2 independent graders.

None of the SCP images had projection artifact before or after 3D-PAR. Scans of the DCP presented projection artifact in 96.5% of the cases. After 3D-PAR, 14.7% had a complete improvement of projection artifact, 56.5% had a partial improvement, 14.1% were worse, and 14.7% presented no change. In the OR, 2.9% had projection artifact, with a complete improvement after 3D-PAR in 40%, partial improvement in 20%, and no change in 40%. Projection artifact was initially present in 97.6% of the images in the CC. After 3D-PAR, there was a complete improvement in 72.9%, partial improvement in 26.5%, and no change in 0.6%. Choroidal neovascularization (CNV) was detected in 29 eyes (17.1%), and 3D-PAR improved detection of CNV in 12 cases (41.4%).

OCTA with 3D-PAR technology minimizes the appearance of projection artifacts in the DCP and CC slabs.

Recent publications have reported that the deep capillary plexus (DCP) area of the foveal avascular zone (FAZ) is significantly larger in eyes following pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) repair when compared with controls. To the best of the authors’ knowledge, there have been no publications on the evaluation of the macular microvasculature using optical coherence tomography angiography (OCTA) in post–pneumatic retinopexy (PnR) eyes. Therefore, the purpose of this study was to investigate FAZ-area changes following PnR.

This retrospective cohort included 19 patients with macula-off RRD who underwent PnR repair. Each patient’s fellow eye was used as a control. The FAZ area in the superficial capillary plexus and DCP was investigated with OCTA and the areas were measured by 2 masked graders.

Both superficial (PnR: 0.22 [0.16-0.35] vs control: 0.24 [0.18-0.34] mm²; P = .715) and deep (PnR: 0.56 [0.51-0.76] vs control: 0.7 [0.59-0.89] mm²; P = .105) FAZ areas were not significantly different between eyes.

Our results suggest that the lack of FAZ-area enlargement after PnR repair may indicate that there is less ischemic damage to the retinal capillary plexus in the fovea when compared with that described in the literature for PPV. The PIVOT trial demonstrated that PnR is associated with superior visual acuity and less metamorphopsia when compared with PPV at 1 year. The results of the current study may provide insight into the potential advantages of PnR. Further studies are needed to elucidate how the macular microvasculature is affected after RRD and to clarify how the FAZ area changes following PnR and PPV.

This study evaluates the vascular development of premature infants at 50 weeks postconception after treatment with intravitreal bevacizumab for type 1 retinopathy of prematurity (ROP).

A retrospective case series was conducted on type 1 ROP neonates with a high risk of general anesthesia complications. Patients were treated with bevacizumab between February 2013 and February 2016. At 50 weeks’ gestational age, all patients were imaged with RetCam (Clarity Medical Systems, Inc) fundus photographs and widefield fluorescein angiography (FA).

There were 4 boys and 7 girls with an average gestational age of 24.8 weeks and weight of 734.3 grams at birth. The estimated gestational age at injection was 37.1 weeks. Examination under anesthesia with FA was performed at a mean of 61 weeks posttreatment. Nineteen of 20 eyes (95%) of 11 infants had incomplete vascularization and peripheral nonperfusion on imaging. FA showed new vessels with increased tortuosity, microvascular abnormalities, and leakage past the original ridge. These 19 patients were treated with confluent ablative photocoagulation to the peripheral nonperfused retina. Patients were followed for a mean of 73.3 weeks after birth. None required incisional surgery.

Patients with type 1 ROP treated with bevacizumab may have delayed vascularization of the peripheral retina and even late recurrence of active disease. Clinicians should regularly monitor patients after bevacizumab for potential neovascular complications.

The purpose of this study is to determine the significance of disorganization of the retinal inner layers (DRIL) in patients with retinal vein occlusions (RVOs) and whether this is influenced by the choice of antivascular endothelial growth factor (anti-VEGF) agent used.

A retrospective chart study was conducted on patients with RVO and center-involved macular edema (ME) presenting to the University of Wisconsin with a minimum follow-up time of 12 months. Medical records were reviewed for demographics, vision, and imaging at baseline and 2 study visits over the course of 1 year. Two masked graders evaluated spectral-domain optical coherence tomography scans for DRIL and other features within the 1-mm-wide area centered on the foveal depression.

Twenty-two eyes had DRIL at baseline. DRIL resolved in 10 eyes at the first study visit, and in 2 more eyes at the second study visit. Although we could not establish an association between visual acuity (VA) and DRIL at baseline, we found a more robust correlation between DRIL extent and VA at baseline in eyes with central retinal vein occlusion/hemicentral vein occlusion compared to eyes with branch retinal vein occlusion. There was an association between DRIL improvement at the first study visit and VA improvement at the second study visit (P = .049). However, this effect was smaller than the effect of initial VA improvement on final VA improvement. No significant difference in DRIL change was observed between the 3 anti-VEGF treatment algorithms: bevacizumab only, aflibercept only, and bevacizumab followed by aflibercept. Additionally, there was no significant correlation between RVO risk factors and change in DRIL over time.

In our study, DRIL was not associated with VA in RVO-ME, but its resolution was predictive of VA improvement in response to anti-VEGF therapy. The choice of anti-VEGF agent (bevacizumab, aflibercept or a combination of the 2) did not affect the magnitude of DRIL resolution in RVO.

This work identifies predictive variables associated with culture-positive cases of acute endophthalmitis after vascular endothelial growth factor (VEGF) inhibitor injection.

A retrospective review of cases of endophthalmitis following intravitreal anti-VEGF injection was performed. All patients received a vitreous biopsy or anterior chamber aqueous biopsy (if vitreous biopsy was not successful) that was sent for microbial cultures before initiation of treatment.

During a 10-year period, 258 357 anti-VEGF agent injections were performed, of which 40 patients (0.016%) developed presumed endophthalmitis. Sixty percent (n = 24) of the presumed endophthalmitis patients had a positive culture. In multivariable logistic analysis, patients who had a best-corrected visual acuity (BCVA) worse than 20/400 were 35.3 times (adjusted odds ratio [AOR], 95% CI, 2.2-576.1, P = .012) more likely to have a positive culture compared with those who had a BCVA of 20/400 or better. Patients who had pain at initial presentation were 27.0 times (AOR, 95% CI, 1.4-523.9, P = .029) more likely to have a positive culture compared with those who did not have pain at initial presentation. Age, sex, clinical diagnosis, smoking status, anti-VEGF agent injected, duration between last anti-VEGF injection and symptoms of endophthalmitis, duration between endophthalmitis symptoms and initial treatment, intraocular pressure at initial presentation, and presence of hypopyon were not associated with a difference in positive-culture yield.

Visual acuity worse than 20/400 and pain at time of initial presentation secondary to endophthalmitis following anti-VEGF injection were strongly associated with a positive culture. Our data support consideration of vitrectomy in cases in which microbe identification is paramount.

The objective of this study was to compare intraocular pressure (IOP) and inflammatory outcomes between patients receiving a single subconjunctival triamcinolone acetonide injection at the end of surgery and those receiving subconjunctival dexamethasone at the end of surgery plus a traditional topical steroid drop taper.

A retrospective consecutive case series compared patients operated on by 2 surgeons, both utilizing 500 mL BSS-PLUS (balanced salt solution with bicarbonate, dextrose, and glutathione; Alcon Laboratories, Inc) infusion solution containing 10 mg dexamethasone, which is added to the solution in the operating room or at the pharmacy. However, one surgeon utilized a single 4 mg triamcinolone acetonide subconjunctival injection at the end of surgery, without additional steroid drops (intervention group), and the other utilized subconjunctival dexamethasone plus a traditional topical steroid taper over a period of 4 to 6 weeks (control group).

There were 161 surgeries in the intervention group and 163 in the control group. No statistically significant differences were found in the usage rate of additional IOP-lowering drops, IOP > 29 mmHg, or IOP increase ≥ 10 mmHg over baseline during the follow-up period. Inflammatory complications were rare in both groups. Five percent of those in the intervention group received supplemental topical steroid drops postoperatively.

A single subconjunctival triamcinolone acetonide injection at the end of surgery may represent a reasonable alternative to requiring patients to use a steroid drop taper following vitreoretinal surgery.

This cross-sectional, randomized, single-blinded study evaluates simulated surgical skills during digitally assisted vitreoretinal surgery (DAVS) with different camera aperture settings to determine maximal surgical performance and preference.

Fifteen retina fellows performed 3 different surgical simulator tests with a DAVS visualization system. To evaluate maximal surgical performance and preference, DAVS was evaluated at different camera apertures (30% and 75%) with a fixed magnification (12×) and television (TV) viewing distance (1.2 m [4 ft]). Comparisons were made of the time needed to complete each test as well as the number of errors. At the end of the 3 tests, participants were asked for their camera aperture preference.

The time it took to perform each simulated surgical test was significantly less with the 30% aperture than with the 75% aperture (P = .036). Furthermore, the number of errors made with the 30% aperture was always less than with the 75% aperture (P = .009). After completing all tests, evaluation of surgeon preference for camera aperture settings showed that 83% of the participants preferred the 30% aperture over the 75% aperture.

Optimization of DAVS parameters directly influences surgical performance. A 30% camera aperture in DAVS outperforms larger camera apertures, not only in depth of field and lateral resolution values, but also in simulated surgical skills. A smaller number of errors, as well as less time needed to complete tests, was achieved with these settings. We suggest that the optimal settings for DAVS enhancement are a 30% camera aperture and a TV viewing distance of 1.2 m.

This article compares bilateral visual outcomes in patients receiving a vitrectomy in one eye for a full-thickness macular hole (FTMH) who also received ocriplasmin treatment in the fellow eye for symptomatic vitreomacular adhesion (VMA).

This was a multicenter, retrospective study to assess the difference in best-corrected visual acuity (BCVA) in patients receiving a vitrectomy in the eye with an FTMH and ocriplasmin treatment for the fellow eye with symptomatic VMA but no FTMH. Patients initially received either a single injection of ocriplasmin 0.125 mg for symptomatic VMA or a vitrectomy for FTMH. After the first eye was stable following the initial treatment option, the second eye was treated with the opposite modality. BCVA was measured at baseline, month 3, and month 6, with up to 2 years of additional follow-up.

Thirty-six eyes (18 patients) were included in the analysis. Eyes that underwent a vitrectomy for FTMH had a mean baseline BCVA of 20/123 and a final BCVA of 20/53. Eyes receiving ocriplasmin treatment for VMA had a mean baseline BCVA of 20/49 and a final BCVA of 20/33. The median time between the 2 treatments was 5.5 months. Eyes receiving ocriplasmin had a median time to VMA resolution of 4 weeks.

Treatment with ocriplasmin showed successful resolution of VMA and improvement in BCVA, obviating the need for vitrectomy. The current study provides a framework for the treatment of patients with a current FTMH in one eye and VMA without an FTMH in the contralateral eye.

This article reports the clinical features, associations, and outcomes of patients with full-thickness macular hole (MH) formation after pars plana vitrectomy for retinal detachment (RD).

A retrospective, interventional case series is presented of consecutive patients undergoing surgical repair of MH following prior tractional or rhegmatogenous retinal detachment repair from September 2014 to October 2018 at a single vitreoretinal surgery practice. The size of the MH, presence of epiretinal membrane (ERM), rate of MH closure, and visual outcome following repair were evaluated.

A total of 996 cases of rhegmatogenous and tractional retinal detachment repair were identified. The average time from the RD surgery to MH diagnosis was 72 days. The incidence of subsequent MH formation in patients who underwent surgery was 0.8% (8/996). The presence of ERM prior to MH repair was noted in 50% of these cases (4/8). In cases with at least 3 months of postoperative follow-up, MH closure was achieved in 100% of eyes after a single surgery. The mean preoperative visual acuity (VA) was 2.06 logMAR (logarithm of the minimum angle of resolution) units (Snellen equivalent, 20/2296) and significantly improved to 0.72 logMAR units (Snellen, 20/104; P = .017) at the last follow-up after MH repair. All patients had improvement in VA at the final postoperative visit, with a VA of 20/200 or better achieved in 87.5% of cases.

Although MH formation after successful RD repair is uncommon, favorable visual and anatomic results can be obtained.

This article evaluates the influence of baseline diabetic macular edema (DME) on cost-utility analysis of treatment for proliferative diabetic retinopathy (PDR) based on 5-year Diabetic Retinopathy Clinical Research Network (DRCR.net) Protocol S results.

A decision-analysis model calculated comparative cost utility of panretinal photocoagulation (PRP) and intravitreal ranibizumab (IVR) treatment for PDR with and without baseline DME. Centers for Medicare & Medicaid Services data were used to calculate associated modeled costs in a hospital/facility-based and nonfacility setting. Cost utility was calculated based on the preserved visual utility and estimated life years remaining. Sensitivity analyses were performed to evaluate the impact of the model’s assumptions.

The modeled cost per quality-adjusted life year (QALY) of treatment for PDR with baseline DME for 5 years of utility in the facility (nonfacility) setting was $280,919 ($203,444) in the PRP group and $452,387 ($339,319) in the IVR group. The estimated lifetime cost per QALY in the facility (nonfacility) setting was calculated as $84,761 ($50,077) in the PRP group and $314,483 ($230,301) in the IVR group. The cost per QALY of IVR for the first 5 years of treatment was 1.6 to 1.7 times that of PRP, whereas lifetime cost per QALY was 3.7 to 4.6 times higher. When considering all patients regardless of baseline DME status, lifetime cost per QALY of PRP was 8% to 13% higher, whereas IVR was only 1% higher compared with the cost per QALY without baseline DME.

When considering the subset of patients with PDR and baseline DME, PRP maintains a more favorable cost utility compared with IVR. This augments previous reports that PRP has a more favorable cost utility than IVR for PDR without DME, given the marginal visual benefit of IVR.

Intravitreal injection therapy (IVIT) has transformed the management of many chorioretinal diseases. Although these treatments are effective, they can also be expensive. Using the Medicare Provider and Utilization Data Report (MPUDR), we aim to quantify the costs of these drugs to Medicare and to project future cost trends.

Data were harvested from the MPUDR for all ophthalmology providers who delivered intravitreal injections (IVT) (CPT code 67028) during the years 2012-2016. Linear regression utilizing the MPUDR data was used to analyze cost trends and to project Medicare costs out to year 2026.

From 2012 to 2016, the total number of IVTs increased from 2 286 593 to 2 936 274 (R² = 0.98; P = .001). The per-beneficiary Medicare cost rose significantly from $3,148 to $3,945 (R² = 0.92; P = .03). The total cost to Medicare for IVIT increased from $1.68 billion to $2.73 billion (R² = 0.99; P < .005). IVIT accounts for 37% of all ophthalmology Medicare reimbursements. At the current rate, IVIT costs will exceed $5 billion per year by 2026.

The total number of injections and costs for IVIT rose significantly from 2012 to 2016. At the current rate, Medicare reimbursement for brand-name drugs will make up a large proportion of future costs.

This article aims to determine preferences and demographics for listeners of an ophthalmology podcast, since podcasts are gaining favor for medical education.

The present study used a cross-sectional, online survey as well as Podtrac, Inc and Squarespace, Inc platform analytics to examine perceived educational usefulness of podcasts for listeners.

Quarterly episode downloads increased from 684 in first-quarter 2017 to 16 016 in third-quarter 2018. A total of 102 participants completed the survey: 82 (80.4%) men and 68 (66.7%) retina attending physicians or fellows. Most respondents listened to “stay up to date” or “learn more about the field of retina” (67; 65.7% each). Most respondents agreed that podcasts are useful for medical education and result in changes in practice, but not that podcasts have surpassed traditional educational methods. For respondents, there was no difference in perceived usefulness between podcasts and peer-reviewed journals, textbooks, continuing medical education lectures, or national conferences; these did not differ with respondent listening histories.

Podcasts are valuable adjuncts for distributing clinically relevant material.

This work investigates the clinical features of cilioretinal artery occlusion (CLRAO) in the setting of optic disc edema.

A retrospective chart review of 3 patients with concomitant CLRAO and optic disc edema was performed. All patients underwent multimodal imaging and systemic workup.

The patients were female, had a median age of 32 years, and were otherwise healthy. Presenting visual acuities were hand motion, 20/1000, and 20/70. One patient had optic nerve enhancement on magnetic resonance imaging. Systemic workups were noncontributory. All patients had ischemic retinal whitening and inner-retinal thinning in the cilioretinal artery (CLRA) distribution. Fluorescein angiography showed no signs of capillary nonperfusion, vascular inflammation, or frank vein occlusion. One patient was lost to follow-up and 2 were treated with high-dose corticosteroids with improvement in visual acuity.

CLRAO can be associated with optic disc edema in the absence of outright central retinal vein occlusion, giant-cell arteritis, or known systemic disease.

This article reports a case of sympathetic ophthalmia (SO) following complications from bilateral intravitreal aflibercept injections, including infectious endophthalmitis requiring vitreoretinal surgery in the left eye (OS) and sterile intraocular inflammation in the right eye (OD), and describes the aqueous cytokine profile of this patient.

The patient was a 51-year-old man with SO. Cytokine levels in the aqueous humor of the sympathizing eye were measured at presentation.

A patient being treated with bilateral aflibercept injections for diabetic macular edema developed infectious endophthalmitis OS requiring a pars plana vitrectomy and sterile intraocular inflammation OD, which subsequently led to SO. Enucleation of the exciting eye (OS) was performed and histopathology confirmed the diagnosis. Cytokine levels in the sympathizing eye revealed high concentrations of intercellular adhesion molecule-1, inducible protein-10, and interleukin-8 and -10.

SO can occur after vitreoretinal surgery for endophthalmitis in the exciting eye and sterile intraocular inflammation in the sympathizing eye following aflibercept injections.

This article reports a case of the dislocation of a scleral-fixated enVista MX60 (Bausch + Lomb) intraocular lens (IOL) secondary to eyelet fracture at the point of contact with a Gore-Tex (W.L. Gore & Associates) suture.

A case report is discussed.

An 81-year-old woman presented with decreased vision secondary to a dislocated Gore-Tex scleral-sutured enVista MX60 IOL in the left eye 14 months after surgery. The patient returned to the operating room for IOL exchange, and intraoperatively it was confirmed that the eyelet of the lens had fractured secondary to tension from the Gore-Tex suture.

To the best of the authors’ knowledge, this is the first report of eyelet fracture in an enVista MX60 scleral-sutured IOL secondary to tension from a Gore-Tex suture.